|Ahead of print publication
Safeguarding essential health services during emergencies: lessons learnt from the COVID-19 pandemic
Poonam Khetrapal Singh1, Manoj Jhalani2
1 WHO Regional Director for South-East Asia, India
2 Director, Department of Health Systems Development, WHO Regional Office for South-East Asia, New Delhi, India
|Date of Web Publication||26-Aug-2020|
Director, Department of Health Systems Development, WHO Regional Office for South-East Asia, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this URL:|
Khetrapal Singh P, Jhalani M. Safeguarding essential health services during emergencies: lessons learnt from the COVID-19 pandemic. WHO South-East Asia J Public Health [Epub ahead of print] [cited 2020 Nov 26]. Available from: http://www.who-seajph.org/preprintarticle.asp?id=293433
The coronavirus disease 2019 (COVID-19) pandemic has affected all aspects of daily life across all sectors worldwide. , The pandemic is nevertheless first and foremost a health crisis, and has severely impacted the health sector. Countries of the World Health Organization (WHO) South-East Asia Region have faced immense challenges in responding to the crisis while maintaining essential health services, owing in part to underprepared medical and public health infrastructures and overwhelmed health workforces. Across the region, countries have experienced shortages of personal protective equipment for health-care workers, ventilators for critical care patients, supplies of essential medicines and even disinfectants for public health measures.
Between May and July 2020, WHO carried out a rapid situation assessment survey on the impact of the pandemic on the continuity of essential health services during the  months prior to the date of survey submission.3 Across the region, the survey revealed constrained access for pregnant women to antenatal check-ups, delivery and postnatal care, and for children to diarrhoea and pneumonia treatment and routine immunization services. In addition, supplementary polio immunization campaigns and the measles, mumps and rubella vaccination drives were suspended. 
These shortfalls in services occurred despite movement to provide or to access health care being exempted from so- called "lockdown" restrictions. Adding to these challenges, misinformation, rumours and the stigmatization of people with COVID-19 have made communities hesitant to use essential health services that continue to function. Upholding and maintaining people's trust in existing health systems and service delivery provision is as important as ensuring that essential health services remain functional in any disaster or health emergency.
| Universal health coverage - now more than ever|| |
Health resilience is strongly promoted by the Sendai Framework for Disaster Risk Reduction 2015-2030, which emphasizes the need for new and existing hospitals and other health facilities that remain safe, effective and operational during and after disasters.  In an emergency, it is not sufficient that safe, accessible and affordable health care is available to only that part of the population already served by such facilities and services; these services must also be accessible to the most vulnerable and hard-to-reach populations. Universal health coverage is not only important in its own right but also central to achieving health for all, health security and the health-related Sustainable Development Goals. ,
As a result of the pandemic, demand will increase for essential health services in the private health-care sector, where price regulation is lacking. This is likely to lead to an increase in out-of-pocket expenditure that will exacerbate financial hardship. The WHO South-East Asia Region will be especially affected, since domestic public spending on health is generally low and out-of-pocket spending is the dominant source of financing - more than 50% of the current health expenditure in five countries of the region.
People in the region are already heavily affected by the double burden of noncommunicable diseases and infectious diseases, in addition to the threat of multiple hazards. They must therefore have equitable and easy access to essential health services at an affordable price, especially in the aftermath of a disaster or in a health emergency situation. Restoring and maintaining essential health services and public health programmes throughout the pandemic response and into the recovery and beyond is of paramount importance for the region to strengthen health security and ensure that its progress across all areas of health is protected and built on. To do that, Member States must adapt, reorient and prioritize investments in the health sector. 
| Building on commitments to sustain essential health services|| |
The COVID-19 pandemic highlights how an immediate threat to human health can bring entire populations, economies and national systems to an abrupt halt. Among other interventions, national ministries of health both in the region and globally have sought to halt the spread of severe acute respiratory syndrome coronavirus 2 by applying public health and social measures to entire districts or states. The unprecedented action taken to mobilize resources, arrange emergency medical products and organize general logistics - despite several bans on international and domestic travel and the closure of points of entry - reflects Member States' commitment to protecting the health and well- being of their people. This commitment can also be witnessed in Member States' resolve to maintain essential health services, which was expressed during the meeting organized by the Regional Director with the ministers of health on 6 August 2020. Before COVID-19, countries of the WHO South-East Asia Region had some of the world's fastest-growing economies.
Now, the World Bank estimates a fall in projected average per capita gross domestic product for countries in the region from US$ 4100 to US$ 3800 this year.  This unprecedented global downturn has significant implications. Health financing in much of the region relies heavily on government health spending and household out-of-pocket payments. The pandemic has significantly reduced both sources of expenditure and will therefore reduce per capita health spending, substantially jeopardizing efforts to achieve universal health coverage. This underlines the critical need to increase public investment in health as a key determinant of social and economic development.
Considering the increasing vulnerabilities and exposure of people across the region to multiple and diverse hazards, risks and threats, it is crucial that the Member States consolidate, expand and intensify ongoing efforts to strengthen core capacities for health emergencies, as specified in the International Health Regulations, 2005.  Accelerated and adequately funded activities to strengthen core capacities, especially at subnational levels, will help to create more resilient health systems that are closer to communities.
It is imperative that Member States develop a roadmap for sustaining essential health services and public health programmes in the context of COVID-19. There is an urgent need to adjust governance and coordination mechanisms to support action in a timely manner and to strengthen coordination and communication among incident managers, programme managers, and public and private sector providers. Continuous monitoring of the delivery of essential services and the provision of timely information to decision-makers - both technical and financial - are vital. An extensive list of sample indicators for monitoring essential health services during the COVID-19 pandemic is available.  Indicators should draw on existing ones routinely reported and should be disaggregated if possible (e.g. by age and sex) to aid in addressing vulnerable, underserved and poor populations.
The functional mapping of systems and resources, the harnessing of digital technology such as tele-health service delivery pathways, and the establishment of safe and effective patient flows in health facilities can help optimize essential health services as part of a "new normal" that includes physical distancing, the wearing of masks and avoiding unnecessary journeys. Health authorities should prioritize making timely, clear and appropriate information available to households and communities, especially vulnerable patients with chronic health conditions.
Risk communication and community engagement strategies should be locally adapted to overcome psychological, social or physical barriers to accessing health services. A whole- of-society approach is required to foster collaboration and partnerships among public, private and civil society stakeholders. Improving health literacy is key to managing any health challenge, including the community response to an outbreak. Special interventions should target vulnerable populations, including people living in urban slums, homeless people, migrant workers, refugees and internally displaced persons, and people in detention centres and prisons.
| Conclusion|| |
The COVID-19 pandemic has revealed gaps in health system resilience in countries of the WHO South-East Asia Region. In doing so, the pandemic has provided governments with an opportunity to recognize and fill those gaps to better protect against future shocks. The existing core capacities for health emergencies must be more risk-informed, better funded and strengthened through cross-sectoral synergies and linkages. The principles of the right to life, the right to health and universal health coverage must continue to guide efforts to build community and health system resilience. Improving the awareness and health literacy of populations, policy-makers and the health workforce is key to preventing and controlling any disease that threatens the safety and security of populations in the region.
| References|| |
Rapid assessment of continuity of essential health services during the COVID-19 pandemic. Geneva: World Health Organization; 2020.
Ofrin RH, Bhola AK, Buddha N. Turning commitments into actions: perspectives on emergency preparedness in South-East Asia. WHO South-East Asia J Public Health. 2020 Apr;9(1):5-14. http://doi.org/10.4103/2224-3151.282989